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Abstract

Driven by research studies and national targets, sedation practices in Intensive care
Units (ICU) are undergoing change. Traditionally, ventilated patients in ICUs were
kept deeply sedated and only gradually ‘weaned off’ sedation. However, current
evidence supports a more ‘wakeful’ patient with the introduction of ‘sedation holds’
encouraging them to regain consciousness (Kress et al. 2000). There is little research
exploring ICU nurses’ assessment and management of sedation. Employing a
Heideggerian, hermeneutic phenomenological approach to enquiry, the study sought
to provide insights into the world of the critical care nurse, nursing with technology,
and specifically their beliefs surrounding sedation practices and how organisational
factors, knowledge and personal experiences influence their clinical decisions in the
care of the ventilated patient.
The setting was the Royal Infirmary of Edinburgh, ICU and the purposive sample
consisted of 16 ICU nurses with diverse critical care nursing experience. Bedside
interviews, utilising an aide memoir, elicited narratives about the nurses’ experiences
of sedation practice and a novel sedation monitor (responsiveness). The
phenomenological analysis drew upon a number of existing frameworks to guide
enquiry. The researcher engaged with the ‘hermeneutic circle’, acknowledging her
pre-understandings and using these as a platform to move between the whole of the
research and the parts, the descriptions and narratives offered, to develop new
knowledge. Themes emerged that demonstrated patients’ sedation status directly
impacted upon the nurses’ ICU lived experiences and left them in a state of
disequilibrium regarding the requirement to deliver research based care, the desire to
deliver holistic care and the duty to deliver safe care. The nurses perceived sedation
holds and ‘wakefulness’ as resulting in patient agitation and distress which affected
patient safety and comfort. However, the nurses equally felt a pressure of obligation
to the doctors to perform such evidence based sedation holds. They described the
struggling to maintain patient safety and manage their own fears and anxieties and
organisational constraints, whilst experiencing guilt, blame and failure associated
with their behavioural discordance with the prescribed decisions and their own
clinical decision making processes and strategies. Team work between the two professions and effective leadership is evidently less than ideal. Consequently the
implementation of changes in sedation practice is failing to meet either the national
targets or to respond to the nurses’ concerns regarding their patient’s short term
wellbeing. On both counts this potentially impairs the pursuit of best practice.